Thibault Richard, MD; Dany Brohee, PhD; Alain Van Meerhaeghe, MD; Michel Vanhaeverbeek, MD
Potential Conflicts of Interest: None disclosed.
Richard T, Brohee D, Van Meerhaeghe A, Vanhaeverbeek M. Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus. Ann Intern Med. 2012;157:76. doi: 10.7326/0003-4819-157-1-201207030-00018
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Published: Ann Intern Med. 2012;157(1):76.
TO THE EDITOR:
In the recent ACP clinical guideline (1), Qaseem and colleagues recommend the addition of a second agent in patients with persistent hyperglycemia despite metformin use and lifestyle modifications (Grade: strong recommendation, high-quality evidence). We do not agree with this level of recommendation.
Our main concern is that the superiority of dual therapy over metformin alone has only been validated by use of a surrogate outcome (that is, the HbA1c level). There are many examples in recent years of evidence founded on surrogate end points, which provide no benefit—or even harm—to patients when hard end points are considered. The effect of an intensive glycemic control on hard end points is doubtful in type 2 diabetes—indeed, several recent meta-analyses have shown no effect on mortality and little effect on vascular complications (2, 3).
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